Provider Demographics
NPI:1497809818
Name:PREMIUM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PREMIUM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EYAEMA
Authorized Official - Middle Name:EKENG
Authorized Official - Last Name:AANAMNDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-957-3300
Mailing Address - Street 1:17065 DIXIE HWY
Mailing Address - Street 2:SUITE 24
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1376
Mailing Address - Country:US
Mailing Address - Phone:708-957-3300
Mailing Address - Fax:708-957-3385
Practice Address - Street 1:17901 GOVERNORS HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1144
Practice Address - Country:US
Practice Address - Phone:708-957-3300
Practice Address - Fax:708-957-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy